Sclerotherapy of bleeding esophageal varices in schistosomiasis. Comparative study in patients with and without previous surgery for portal hypertension

DOES THE DROP IN PORTAL PRESSURE AFTER ESOPHAGOGASTRIC DEVASCULARIZATION AND SPLENECTOMY INFLUENCE THE VARIATION OF VARICEAL CALIBERS AND THE REBLEEDING RATES IN SCHISTOSOMIASIS IN LATE FOLLOW-UP?

Background:

The treatment of choice for patients with schistosomiasis with previous episode of varices is bleeding esophagogastric devascularization and splenectomy (EGDS) in association with postoperative endoscopic therapy. However, studies have shown varices recurrence especially after long-term follow-up.

Aim:

To assess the impact on behavior of esophageal varices and bleeding recurrence after post-operative endoscopic treatment of patients submitted to EGDS.

Methods:

Thirty-six patients submitted to EGDS were followed for more than five years. They were divided into two groups, according to the portal pressure drop, more or less than 30%, and compared with the behavior of esophageal varices and the rate of bleeding recurrence.

Results:

A significant reduction on the early and late post-operative varices caliber when compared the pre-operative data was observed despite an increase in diameter during follow-up that was controlled by endoscopic therapy.

Conclusion:

The drop in portal pressure did not significantly influence the variation of variceal calibers when comparing pre-operative and early or late post-operative diameters. The comparison between the portal pressure drop and the rebleeding rates was also not significant.

Diagnosis and clinical management of hepatosplenic schistosomiasis: A scoping review of the literature

BACKGROUND

Hepatosplenic schistosomiasis (HSS) is a disease caused by chronic infection with Schistosma spp. parasites residing in the mesenteric plexus; portal hypertension causing gastrointestinal bleeding is the most dangerous complication of this condition. HSS requires complex clinical management, but no specific guidelines exist. We aimed to provide a comprehensive picture of consolidated findings and knowledge gaps on the diagnosis and treatment of HSS.

METHODOLOGY/PRINCIPAL FINDINGS

We reviewed relevant original publications including patients with HSS with no coinfections, published in the past 40 years, identified through MEDLINE and EMBASE databases. Treatment with praziquantel and HSS-associated pulmonary hypertension were not investigated. Of the included 60 publications, 13 focused on diagnostic aspects, 45 on therapeutic aspects, and 2 on both aspects. Results were summarized using effect direction plots. The most common diagnostic approaches to stratify patients based on the risk of variceal bleeding included the use of ultrasonography and platelet counts; on the contrary, evaluation and use of noninvasive tools to guide the choice of therapeutic interventions are lacking. Publications on therapeutic aspects included treatment with beta-blockers, local management of esophageal varices, surgical procedures, and transjugular intrahepatic portosystemic shunt. Overall, treatment approaches and measured outcomes were heterogeneous, and data on interventions for primary prevention of gastrointestinal bleeding and on the long-term follow-up after interventions were lacking.

CONCLUSIONS

Most interventions have been developed on the basis of individual groups' experiences and almost never rigorously compared; furthermore, there is a lack of data regarding which parameters can guide the choice of intervention. These results highlight a dramatic need for the implementation of rigorous prospective studies with long-term follow-up in different settings to fill such fundamental gaps, still present for a disease affecting millions of patients worldwide.

Portal vein thrombosis in patients with hepatosplenic schistosomiasis who underwent oesophagogastric devascularization combined with splenectomy

BACKGROUND

Portal vein thrombosis (PVT) has been described in nearly 50% of patients who underwent oesophagogastric devascularization combined with splenectomy (EGDS), but no previous study has compared its occurrence in surgical and non-surgical groups. This study aimed to investigate PVT in hepatosplenic schistosomiasis (HSS) and its association with EGDS and upper variceal bleeding (UVB).

METHODS

Retrospectively, 104 HSS individuals were enrolled. Following EGDS, the occurrence of PVT, mesenteric vein thrombosis (MVT), hospital admissions and UVB were recorded.

RESULTS

EGDS was performed in 27 (26%) patients. PVT and MVT were detected in 30 (33%) and 8 (9.8%) patients, respectively. Patients who underwent EGDS were at greater risk of PVT (63% vs 19.7%; odds ratio [OR] 6.12 [95% confidence interval {CI} 2.3 to 16.1], p<0.001) when compared with a non-surgical approach. There was no significant difference in UVB occurrence and β-blocker usage. PVT was associated with more hospital admissions (p=0.030) and higher alkaline phosphatase levels (p=0.008). UVB occurrence in patients with and without thrombosis was similar. In multivariate analysis, after adjustment, PVT was associated with the surgical approach (OR 4.56 [95% CI 1.55 to 13.38], p=0.006) and age at HSS diagnosis (OR 0.94 [95% CI 0.90 to 0.99], p=0.021).

CONCLUSIONS

EGDS was not associated with a decreased frequency of UVB when compared with the non-surgical approach but was an independent risk factor for PVT.

O ÍNDICE ESPLÊNICO COMO PREDITOR DE SANGRAMENTO E RECIDIVA VARICOSA NO SEGUIMENTO TARDIO DE PACIENTE ESQUISTOSSOMÓTICOS APÓS TRATAMENTO ENDOSCÓPICO EXCLUSIVO

Endoscopic treatment for esophageal variceal has been used as the main intervention in patients with portal hypertension secondary to schistosomiasis, but with significant rates of recurrence of esophageal variceal and rebleeding. The long-term results of exclusive endoscopic treatment are poorly studied as the relationship of the splenic dimensions in this context.

Laparoscopic Treatment of Presinusoidal Schistosomal Portal Hypertension Associated With Postoperative Endoscopic Treatment: Results of a New Approach

AIM

To propose a laparoscopic treatment for schistosomal portal hypertension.

METHODS

Ten patients with schistosomiasis and portal hypertension, with previous gastrointestinal hemorrhage from esophageal varices rupture, were evaluated. Patients were subjected to a laparoscopic procedure, with ligature of splenic artery and left gastric vein. Upper gastrointestinal endoscopy was performed on the 30th postoperative day, when esophageal varices diameter was measured and band ligature performed. During follow-up, other endoscopic procedures were performed according to endoscopy findings.

RESULTS

There was no operative mortality. One patient had a postoperative splenic infarction that was conservatively treated. Mean hospitalization time was 5 days. During endoscopy 30 days after surgery, a decrease in variceal diameters was observed in 6 patients. During follow-up (mean 84 mo), after endoscopic therapy 8 patients had eradicated varices, but 4 presented with recurrence. Considering the late postoperative evaluation, all patients had a decrease in variceal diameters. A mean of 3.8 endoscopic banding sessions were performed per patient. Two patients presented bleeding recurrence; one had a minor bleeding episode and the other had 2 episodes of bleeding varices requiring blood transfusion. In both patients, bleeding was controlled with endoscopic therapy. No late mortality was observed.

CONCLUSIONS

Laparoscopic ligature of the splenic artery and the left gastric vein is a promising and less-invasive method for the treatment of schistosomal portal hypertension.

Late results of esophagogastric devascularization and splenectomy associated with endoscopic treatment in patients with schistosomiasis

BACKGROUND

Schistosomiasis is endemic problem in Brazil affecting about three to four million people, and digestive hemorrhage caused by esophageal varices rupture is the main complication of the disease. Surgical treatment has become a therapeutic option, especially for secondary prophylaxis after at least one episode of bleeding. The surgical technique used by the vast majority of surgeons for the prevention of rebleeding is esophagogastric devascularization and splenectomy. Although with good postoperative results, rebleeding rate is significant, showing the need to follow-up endoscopy in all patients.

AIM

To evaluate long-term results of patients submitted to esophagogastric devascularization and splenectomy and postoperative endoscopic treatment regarding esophageal varices caliber and rebleeding rates.

METHODS

A retrospective study of 12 patients underwent esophagogastric devascularization and splenectomy followed for more than five years.

RESULTS

All patients showed varices size reduction, and no patient had postoperative bleeding recurrence.

CONCLUSION

Esophagogastric devascularization and splenectomy decreased significantly the esophageal variceal size when associated with endoscopic follow-up, being effective for bleeding recurrence prophylaxis.

Splenic artery ligature associated with endoscopic banding for schistosomal portal hypertension

AIM: To propose a less invasive surgical treatment for schistosomal portal hypertension.

METHODS: Ten consecutive patients with hepatosplenic schistosomiasis and portal hypertension with a history of upper gastrointestinal hemorrhage from esophageal varices rupture were evaluated in this study. Patients were subjected to a small supraumbilical laparotomy with the ligature of the splenic artery and left gastric vein. During the procedure, direct portal vein pressure before and after the ligatures was measured. Upper gastrointestinal endoscopy was performed at the 30^th postoperative day, when esophageal varices diameter were measured and band ligature performed. During follow-up, other endoscopic procedures were performed according to endoscopy findings.

RESULTS: There was no intra-operative mortality and all patients had confirmed histologic diagnoses of schistosomal portal hypertension. During the immediate postoperative period, two of the ten patients had complications, one characterized by a splenic infarction, and the other by an incision hematoma. Mean hospitalization time was 4.1 d (range: 2-7 d). Pre- and post-operative liver function tests did not show any significant changes. During endoscopy thirty days after surgery, a decrease in variceal diameters was observed in seven patients. During the follow-up period (57-72 mo), endoscopic therapy was performed and seven patients had their varices eradicated. Considering the late postoperative evaluation, nine patients had a decrease in variceal diameters. A mean of 3.9 endoscopic banding sessions were performed per patient. Two patients presented bleeding recurrence at the late postoperative period, which was controlled with endoscopic banding in one patient due to variceal rupture and presented as secondary to congestive gastropathy in the other patient. Both bleeding episodes were of minor degree with no hemodynamic consequences or need for blood transfusion.

CONCLUSION: Ligature of the splenic artery and left gastric vein with supraumbilical laparotomy is a promising and less invasive method for treating presinusoidal schistosomiasis portal hypertension.

Clinical management of advanced schistosomiasis: a case of portal vein thrombosis-induced splenomegaly requiring surgery

We report for the first time in the Philippines a case of portal vein thrombosis in a 12 year old Filipino boy with advanced schistosomiasis. The boy was referred to the Research Institute for Tropical Medicine (RITM), Manila, due to a rapidly enlarging spleen post-praziquantel treatment. At RITM, liver function tests were within normal limits but complete blood examinations showed pancytopenia and abnormal coagulation times. Serum markers for hepatitis A, B and C were negative. Abdominal MRI revealed schistosome-induced periportal fibrosis. The main portal vein appeared thrombosed with characteristic cavernous transformation of the right portal vein. Varices were seen in the oesophagus, gastrohepatic ligament, and splenic hilum. The spleen was markedly enlarged, with parenchymal foci representing Gamna-Gandy bodies. The patient underwent splenectomy. Histopathologic findings in the liver showed moderate pipestem fibrosis and schistosome egg granulomas. The patient was discharged from the hospital in excellent clinical condition.

Trashepatic left gastric vein embolization in the treatment of recurrent hemorrhaging in patients with schistosomiasis previously submitted to non-derivative surgery

CONTEXT

Non-derivative surgical techniques are the treatment of choice for the control of upper digestive tract hemorrhages after schistosomotic portal hypertension. However, recurrent hemorrhaging due to gastroesophagic varices is frequent.

OBJECTIVE

To evaluate the outcome of treatment based on embolization of the left gastric vein to control the reoccurrence of hemorrhages caused by gastroesophagic varices in patients with schistosomiasis previously submitted to non-derivative surgery.

METHODS

Rates of reoccurrence of hemorrhages and the qualitative and quantitative reduction of gastroesophagic varices in patients undergoing transhepatic embolization of the left gastric vein between December 1999 and January 2009 were studied based on medical charts and follow-up reports.

RESULTS

Seven patients with a mean age of 39.3 years underwent percutaneous transhepatic embolization of the left gastric vein. The mean time between azigoportal disconnections employed in combination with splenectomy and the percutaneous approach was 8.4 ± 7.3 years, and the number of episodes of digestive hemorrhaging ranged from 1 to 7 years. No episodes of reoccurrence of hemorrhaging were found during a follow-up period which ranged from 6 months to 7 years. Endoscopic postembolization studies revealed reductions in gastroesophagic varices in all patients compared to preembolization endoscopy.

CONCLUSIONS

Percutaneous transhepatic embolization of the left gastric vein in patients with schistosomiasis previously submitted to surgery resulted in a decrease in gastroesophagic varices and was shown to be effective in controlling hemorrhage reoccurrence.

Esplenectomia e ligadura da veia gástrica esquerda na esquistossomose mansônica: efeitos sobre pressão das varizes do esôfago e indicadores endoscópicos de risco de sangramento por varizes esofagogástricas

RACIONAL: Expressivo contingente de pacientes esquistossomóticos com a forma hepatoesplênica e hipertensão portal apresentam hemorragia causada pela ruptura de varizes esofagogástricas, principal causa de alta morbidade e mortalidade da doença. OBJETIVO: Investigar os efeitos da esplenectomia e ligadura da veia gástrica esquerda sobre fatores de risco de sangramento por varizes esofagogástricas em portadores de esquistossomose mansônica, forma hepatoesplênica, com antecedente de hemorragia digestiva alta. MÉTODO: Estudaram-se, de forma prospectiva, 34 pacientes, com idade entre 1 e 74 anos (média 44,14), sendo 18 (53%) mulheres. Analisaram-se: 1) pressão das varizes do esôfago, aferida pela técnica endoscópica do balão pneumático; 2) tamanho, local, cor e sinais de cor vermelha nas varizes do esôfago; 3) varizes gástricas e gastropatia da hipertensão portal. Realizaram-se avaliações no pré-operatório, no pós-operatório imediato e no sexto mês após a ligadura da veia gástrica esquerda. RESULTADOS: A pressão das varizes do esôfago diminuiu de 22,3+/-2,6 mmHg, antes da operação, para 16,0+/-3,0 mmHg no pós-operatório imediato (p<0,001), caindo para 13,3+/-2,6 mmHg no pós-operatório do sexto mês (p<0,001). A proporção de varizes de grosso calibre, varizes no esôfago superior, varizes de cor azul, varizes com sinais de cor vermelha e de gastropatia da hipertensão portal decresceu de forma significante apenas no sexto mês de pós-operatório. CONCLUSÃO: A ligadura da veia gástrica esquerda, em esquistossomóticos hepatoesplênicos, com antecedente de hemorragia digestiva alta, revelou-se eficaz em diminuir alguns dos principais fatores de risco de hemorragia por varizes esofagogástricas, indicando boa perspectiva no controle definitivo do sangramento.

Comparison between endoscopic sclerotherapy and band ligation for hemostasis of acute variceal bleeding

AIM: To compare band ligation (BL) with endoscopic sclerotherapy (SCL) in patients admitted to an emergency unit for esophageal variceal rupture.

METHODS: A prospective, randomized, single-center study without crossover was conducted. After endoscopic diagnosis of esophageal variceal rupture, patients were randomized into groups for SCL or BL treatment. Sclerotherapy was performed by ethanolamine oleate intravascular injection both above and below the rupture point, with a maximum volume of 20 mL. For BL patients, banding at the rupture point was attempted, followed by ligation of all variceal tissue of the distal esophagus. Primary outcomes for both groups were initial failure of bleeding control (5 d), early re-bleeding (5 d to 6 wk), and complications, including mortality. From May 2005 to May 2007, 100 patients with variceal bleeding were enrolled in the study: 50 SCL and 50 BL patients. No differences between groups were observed across gender, age, Child-Pugh status, presence of shock at admission, mean hemoglobin levels, and variceal size.

RESULTS: No differences were found between groups for bleeding control, early re-bleeding rates, complications, or mortality. After 6 wk, 36 (80%) SCL and 33 (77%) EBL patients were alive and free of bleeding. A statistically significant association between Child-Pugh status and mortality was found, with 16% mortality in Child A and B patients and 84% mortality in Child C patients (P<0.001).

CONCLUSION: Despite the limited number of patients included, our results suggest that SCL and BL are equally efficient for the control of acute variceal bleeding.

Long-term results of esophagogastric devascularization and splenectomy associated with endoscopic treatment in schistosomal portal hypertension

BACKGROUND

Esophagogastric devascularization and splenectomy (EGDS) is the most performed operation for prophylaxis of esophageal varices bleeding recurrence in hepatosplenic schistosomiasis. Lower rebleeding rates are obtained through the association of postoperative endoscopic treatment; however, there is a dearth of studies showing long-term results.

METHODS

Clinical, laboratory, and endoscopic data of 97 patients submitted to EGDS with at least 5 years of follow-up, were analyzed.

RESULTS

The mean follow-up was 116.4 months. Bleeding recurrence occurred in 24.7% of patients; however, this percentage was 14.6% when only variceal hemorrhage was considered. Bleeding recurrence occurred in four patients even after endoscopic evaluation demonstrated esophageal varices eradication. In the late follow-up we observed normalization of anemia, leukopenia, thrombocytopenia, hyperbilirubinemia, and a prothrombin activity time increase. No clinical or laboratory hepatic insufficiency was observed.

CONCLUSIONS

The EGDS procedure with postoperative endoscopic treatment led to good clinical results and avoided hemorrhagic recurrence in 75.3% of schistosomal patients. There was improvement of laboratory measures of hepatic function, as well as correction of hypersplenism. Variceal hemorrhagic recurrence may occur even when esophageal varices eradication is reached.

Trombose de veia porta após desconexão ázigo-portal e esplenectomia em pacientes esquistossomóticos: Qual a real importância?

CONTEXTO: A complicação mais frequente após a desconexão ázigo-portal e esplenectomia em doentes com esquistossomose mansônica hepatoesplênica é a trombose da veia porta. OBJETIVOS:Avaliar a incidência, os fatores preditivos dessa complicação, assim como, a evolução clínica, laboratorial, endoscópica e ultrassonográfica desses pacientes. MÉTODOS: Foram analisados retrospectivamente os prontuários de 155 doentes esquistossomóticos submetidos a desconexão ázigo-portal e esplenectomia. RESULTADOS: Trombose de veia porta foi observada em 52,3% dos pacientes, sendo 6,5% de trombose total e 45,8% de trombose parcial. Os pacientes que evoluíram com trombose de veia porta apresentaram mais frequentemente diarreia no pós-operatório. Febre foi evento habitual que ocorreu em 70% dos casos, mais frequente, entretanto, nos doentes com trombose total da veia porta (100%). Trombose de veia mesentérica superior ocorreu em quatro doentes (2,6%), sendo mais frequente entre os com trombose total da veia porta. Não se encontrou diferença estatística quanto aos parâmetros clínicos, laboratoriais, endoscópicos e recidiva hemorrágica no pós-operatório tardio, quando comparados os pacientes com e sem trombose portal. CONCLUSÕES: A trombose de veia porta no pós-operatório da desconexão ázigo-portal e esplenectomia é evento frequente, sem nenhum fator preditivo para sua ocorrência; na maioria dos casos a trombose é parcial e apresenta evolução benigna, com baixa morbidade; trombose total da veia porta está mais frequentemente associada à trombose da veia mesentérica superior, com elevada morbidade; a trombose da veia porta, parcial ou total, não acarretou complicações no período pós-operatório tardio.

Effect of esophagogastric devascularization with splenectomy on schistossomal portal hypertension patients' immunity

BACKGROUND: Surgical treatment of hemorrhagic complication in schistosomal portal hypertension in our hospital is an esophagogastric devascularization procedure with splenectomy. Infectious risks and immunological alterations imputed to splenectomy may have significant importance. To minimize the consequences of spleen absence, the use of subtotal splenectomy and spleen auto-transplantation were stimulated. AIM: To verify the immunologic alterations imposed by this procedure in our patients. METHOD: Twenty-eight patients with schistosomal portal hypertension and previous history of upper digestive bleeding due to esophagogastric varices rupture underwent elective esophagogastric devascularization and splenectomy. They were prospectively studied before esophagogastric devascularization procedure with splenectomy, 15 and 30 days, 3 and 6 months after the procedure. T and B-lymphocytes, CD4 and CD8 subpopulations were determinated by monoclonal antibodies. Immunoglobulins A, M, G and C3, C4 components of the complement were determinated by radial immunodiffusion. RESULTS: We observed important reduction of all immune cells, increase of IgG and normal levels of IgM, IgA, C3 and C4 at preoperative. CD4/CD8 relation was normal. Six months after esophagogastric devascularization procedure with splenectomy, significant increase in T-lymphocytes, CD4, CD8 and B-lymphocytes were observed. CD4/CD8 relation remained normal. We noted significant increase in C3. IgA, IgM, IgG and C4 had increased, but without significant difference. CONCLUSION: Esophagogastric devascularization procedure with splenectomy determines an increase in T and B-lymphocytes, CD4 and CD8 subpopulations without compromising immunoglobulins and components of complement levels.

Schistosomiasis mansoni -- clinical features

In the present review, we will discuss the Schistosoma mansoni form, which is the most widely distributed schistosome in humans and is found both in the Old and New Worlds. The main features of the natural history of mansonic schistosomiasis are reviewed, with emphasis on the clinical forms of the disease, their diagnosis and treatment.

Gut Bacterial Translocation and Postoperative Infections: A Prospective Study in Schistosomotic Patients

BACKGROUND

Bacterial translocation (BT) across the intact intestinal mucosal barrier has been postulated as a source of sepsis in susceptible patients, including those with cirrhosis and portal hypertension. This condition has not been studied in hepatosplenic schistosomiasis, wherein portal hypertension and the presence of an immune deficiency state associated with the parasitic disease could predispose to BT into mesenteric lymph nodes (MLN). A study was conducted to determine the prevalence of aerobic bacteria in MLN (bacterial translocation) of patients with hepatosplenic schistosomiasis, and establish a possible association with postoperative infections.

METHODS

In a series of 51 patients submitted to surgical treatment of schistosomotic portal hypertension with splenectomy and gastric devascularization, MLN were obtained from each patient at the beginning (MLN1) and at the end (MLN2) of the surgical procedure, and sent for bacteriological analysis. Prospective patient evaluation during the postoperative period correlated positive MLN cultures with infectious complications.

RESULTS

The prevalence of aerobic bacteria was 17.6% at MLN1 and 27.5% at MLN2, however, this difference was non-significant (p = 0.24). Bacterial translocation to all MLN was 22.5%. Escherichia coli was the most frequent organism (26.1%, 6/23). The overall incidence of postoperative infections was 19.6% (10/51), with a significant association with the presence of positive cultures of MLN (p = 0.043).

CONCLUSIONS

The findings of this study suggest that the presence of aerobic bacteria on MLN as a consequence of BT may play a role in the development of postoperative infectious complications, particularly in schistosomotic patients.

Efeitos do oleato de etanolamina na parede venosa, de cães

OBJETIVO: Avaliar a resposta biológica que o oleato de etanolamina possa desencadear na parede de veias superficiais normais de cães. MÉTODOS: Utilizados 39 cães, sem raça definida, adultos, machos, com peso variando entre 10 a 18 kg, distribuídos de modo aleatório em três grupos: grupo 1, avaliados após 7 dias, grupo 2, 14 dias e grupo 3, 21 dias. O procedimento foi realizado em duas fases. A primeira constou da injeção de 2 ml do oleato de monoetanolamina a 5%, por punção única na veia cefálica do membro torácico do cão. A segunda, realizada 7, 14 e 21 dias após, constou da retirada da peça operatória, tendo sido executada em três tempos diferentes, conforme o grupo a que pertencia o animal. As veias contralaterais foram extraídas como controle. Para estudo histológico utilizaram-se os métodos de hematoxilina-eosina e tricrômio de Masson. RESULTADOS: A trombose venosa e a organização do trombo ocorreram em todos animais estudados. A recanalização do trombo não foi observada de modo estatisticamente significante, até 21 dias de exame. Encontrou-se lesão de túnica média, que não foi acompanhada de correspondente processo inflamatório. Na túnica adventícia este processo foi visto nos três períodos de tempo estudados. Depósitos de hemossiderina em fagócitos ocorreram aos 14 e 21 dias de experimento. Extravasamento de esclerosante foi observado somente na primeira semana de estudo. Material hialino fibrinóide foi encontrado aos 21 dias de experimento. CONCLUSÕES: O oleato de etanolamina em contato com a parede interna da veia superficial produziu trombose venosa, a qual se organizou em todos os casos, não se observando sua recanalização durante o tempo deste ensaio. Houve lesão da túnica média venosa em todos animais estudados, sem que houvesse processo inflamatório reativo nesse local. Na túnica adventícia venosa surgiu processo inflamatório, além de sinais de extravasamento do esclerosante, da presença de hemossiderina e de material hialino externos à veia.

[Splenectomy plus left gastric vein ligature and devascularization of the great curvature of the stomach in the treatment of hepatosplenic schistosomiasis. Postoperative endoscopic sclerosis is necessary?]

OBJECTIVE

With the intention of evaluating the effectiveness and the maintenance of the postoperative endoscopic sclerosis as routine, in association to splenectomy with left gastric vein ligature and devascularization of the great curvature of the stomach, the present study was accomplished.

METHOD

Between 1992 and 1998, 131 patient were operated in the General Division of the "Hospital das Clínicas" (Federal University of Pernambuco, Recife, PE, Brazil). The medium follow-up was 30 months. All patients were requested to come back to the clinic for accomplishment of clinical and laboratory control. Of the 111 patients that came back to the clinic, 80 patients had a digestive endoscopy done. Of these 80 patients, 36 followed the recommendation and underwent to a postoperative endoscopic sclerosis program (group 1), while 44 did not accomplish postoperative endoscopic sclerosis (group 2).

RESULTS

Regarding the eradication of the esophagus varices, the authors found a statistical difference between the groups (52.7% of the group 1 vs. 18.2% of the group 2). Other analyzed items (mortality, rebleeding rate, thrombosis of the portal vein, gastric varices and degree of periportal fibrosis) statistical relevance was not observed.

CONCLUSION

The association of the postoperative endoscopic sclerosis to the splenectomy with left gastric vein ligature and devascularization of the great curvature of the stomach, in the treatment of schistosomotic portal hypertension with digestive hemorrhage antecedent, should be maintained.

[Hepatosplenic schistosomiasis portal hypertension: effect of esophagogastric devascularization with splenectomy on the diameter and mean flow velocity in the portal system (ultra-sonographic Doppler]

BACKGROUND

Esophagogastric devascularization with splenectomy has been used for the treatment of upper digestive bleeding due to esophagic varices in hepatoportal mansoni's schistosomic portal hypertension. Nevertheless, early portal thrombosis has hampered this surgical technique (13.3% and 53.2%), compromising the good results on the hemorrhagic side. Supposing that portal circulatory changes, due to the surgical treatment, may play an important role in this kind of complication, our objective was to identify the hemodynamic facilitating factors. Portal hemodynamic aspects, identified by ultra-sonographic Doppler study, from two groups of patients: non-operated upon and splenectomized with esophagogastric devascularization in late post-operatory phase (in excess of 6 moths), with portal hypertension due to mansoni hepatoesplenic portal hypertension and in similar clinical conditions, were compared.

METHOD

Fifty eight ambulatorial patients were studied, all had portal hypertension caused by mansoni's hepatosplenic schistosomiasis and previous bouts of digestive bleeding. They were divided in two groups: A--29 followed clinically/endoscopically, and group B--29 previously submitted to esophagogastric devascularization with splenectomy. In all was measured the diameter and mean flow velocity in the portal vein and its right and left branches by ultra-sonographic Doppler study. The results were submitted to statistical analysis for inter- and intra-group comparison.

RESULTS

Group A (non-operated): the portal vein diameter was greater than the right and left branches (10.6 +/- 2.9, 8.0 +/- 1.8, 9.1 +/- 2.6 cm), the mean flow velocities in the portal vein and its branches were similar (15.62 +/- 6.17, 14.92 +/- 5.33, 16.12 +/- 4.18 cm/seg). Group B (operated): the diameter and mean flow velocity in all vessels were reduced (8.8 +/- 1.7, 5.2 +/- 1.2, 7.5 +/- 2.2 cm/12.53 +/- 2.60, 8.86 +/- 1.75, 9.69 +/- 3.75 cm/seg).

CONCLUSIONS

After esophagogastric devascularization with splenectomy, there was a reduction of the diameter and mean flow velocity in the portal vein, its right and left branches.

Esquistossomose hepatoesplênica cirúrgica: histopatologia hepatica e endoscopia digestiva alta em crianças comparadas a adultos

Objetivando melhor compreender a fisiopatologia da esquistossomose grave em adultos e crianças, avaliaram-se diferenças histopatológicas do fígado e do padrão de endoscopia digestiva entre esses pacientes. Vinte e um adultos e igual número de crianças foram incluídos no estudo. Todos foram submetidos a esplenectomia e ligadura da veia gástrica esquerda. Os achados histopatológicos foram avaliados em secções de biópsia hepática. Utilizou-se videoendoscópio para endoscopia digestiva. Nos adultos foram encontradas: 1 - fibrose de Symmers, grau I, em um paciente; grau II, em sete; e grau III, em treze; 2 - atividade inflamatória mínima em cinco; leve, em sete; moderada, em seis; e intensa, em um; ausência de atividade inflamatória, em dois; 3 - mínima granulomatose, em quatro pacientes; moderada, em dois; ausência de granulomas, em quinze; 4 - pigmento esquistossomótico mínimo, em quatro pacientes; moderada, em um; ausência, em dezesseis. Nas crianças, foram encontradas: 1 - fibrose de Symmers, grau I, em um paciente; grau II, em quatro e grau III, em dezesseis; 2 - atividade inflamatória mínima, em sete pacientes; leve, em quatorze; 3 - mínima granulomatose, em seis pacientes; leve, em cinco; moderada, em dois; ausência, em oito; 4 - pigmento esquistossomótico mínimo, em seis pacientes; leve, em três; moderada, em seis; ausência, em seis. Na endoscopia digestiva alta encontrou-se nos adultos: oito (38%) com varizes de médio calibre e treze (62%), de grosso calibre. Oito pacientes (38%) tiveram varizes de fórnix gástrico e cinco (24%), da cárdia. Gastropatia da hipertensão porta foi diagnosticada em dezesseis pacientes (76%). Com relação às crianças, quatro (19%) apresentaram varizes de fino calibre, oito (38%) de médio; e nove (43%) de grosso calibre. Três (14%) tiveram varizes gástricas, sendo duas no fórnix e uma no cárdia. Nove (43%) das crianças apresentavam gastropatia de hipertensão porta. Os achados evidenciaram uma histopatologia hepática similar nos dois grupos; entretanto, as repercussões hemodinâmicas da hipertensão porta foram mais importantes nos adultos, sem, no entanto, alcançar significação estatística.

Recidiva hemorrágica em pacientes esquistossomóticos operados

Foram estudados, no período de 1987 a 1991, trinta doentes esquistossomóticos submetidos anteriormente a operações não descompressivas para tratamento da hemorragia digestiva alta, e que apresentaram recidiva hemorrágica. Através de endoscopia digestiva alta, ultra-sonografia abdominal e estudo angiográfico, procurou-se determinar o local do novo sangramento e quais os possíveis fatores de recidiva hemorrágica presentes. Procurou-se também determinar a influência da cirurgia anterior no intervalo de tempo decorrido entre esta e o primeiro episódio de recidiva hemorrágica. Os autores concluem que as varizes esofágicas foram significativamente o local mais freqüente do sangramento nas recidivas hemorrágicas (86,7%); que a úlcera péptica gástrica (13,3%), a não desvascularização gastroesofágica (30%), a desvascularização incompleta (16,7%) ou a trombose da veia porta (26,7%) estão presentes na maioria dos casos de recidiva hemorrágica; e que a associação da desvascularização gastroesofágica à esplenectomia não alterou o intervalo médio de tempo decorrido entre a cirurgia anterior e o primeiro episódio de recidiva do sangramento.

Splenectomy associated with ligature of the left gastric vein in children with surgical schistosomiasis: analysis of the hepatic functional reserve

Splenectomy and ligature of the left gastric vein in children with hepatosplenic schistosomiasis mansoni and bleeding esophageal varices produce a decrease of the portal hepatic blood flow and increase in the hepatic arterial flow. The effects of these hemodinamic changes in the liver could, theoretically, deteriorate the hepatic functional reserve of these patients. Forty children with this pathology underwent that kind of treatment and they were followed-up, prospectively , mean follow up of 48 months, regard to their hepatic functional reserve. Before surgery, thirteen children were classified as "good risk - grade A" in the Child’s criteria for assessment of the hepatic reserve and twenty seven as "moderate risk - grade B". The mean serum albumin concentration was 3.16g/dl ± 0.62g/dl. Only in one patient the serum bilirubin concentration was slightly greater than 2mg/dl. After surgery, fifteen patients were diagnosed as "good risk - A" and twenty five as "moderate risk - B". The mean serum albumin concentration was 3.25g/dl ± 0.50g/dl. Similarly one patient in the post-operative follow-up has presented with serum bilirubin concentration greater than 2mg/dl. Additionally, after surgery there was a significant improvement in the plasma prothrombin levels. These findings support the idea that there has been no deterioration of the hepatic functional reserve of these patients.

Schistosomiasis. Pathophysiology, diagnosis, and treatment

Globally, schistosomes infect 1 in 30 people. Tourists travel to endemic areas, whereas students, workers, and expatriates travel to nonendemic areas. Physicians around the world need to remain aware of this common parasitic infection. Pathology results from parasite eggs that lodge in the intestines and liver. Intestinal schistosomiasis is most often asymptomatic and presents with occult gastrointestinal bleeding. Hepatosplenic schistosomiasis develops insidiously because of cumulative fibrotic injury. Stigmata of liver failure are absent unless comorbid viral or alcoholic hepatitis is present. Patients with end-stage hepatosplenic schistosomiasis die from variceal hemorrhage. Diagnosis of schistosomiasis is confirmed by finding eggs in stool or biopsy specimens. Antischistosome antibodies may identify infected tourists returning from endemic areas. Circulating schistosome antigens distinguish current from past infections. Praziquantel is the schistosomicidal drug of choice. Most cases of hepatosplenic schistosomiasis resolve after effective treatment. Prophylactic propranolol may prevent hemorrhage in praziquantel-treated patients with high-grade varices. Sclerotherapy is also efficacious. When necessary, patients with hepatosplenic schistosomiasis tolerate decompressive surgery well.

Portal hypertension in mansonic schistosomiasis

Mansonic schistosomiasis is an endemic disease in Brazil, with an estimated 10-12 million people infested. Among its clinical manifestations, the hepatosplenic form causes portal hypertension which, in turn, brings about severe digestive hemorrhage, the most serious complication of the disease. Normally, the patients are young, and have hepatosplenomegaly, hypersplenism without clinical manifestations, and slightly reduced hepatic function. The angiographic findings are characteristic, differing from those of hepatic cirrhosis. In Brazil, the definitive treatment for gastrointestinal hemorrhage is surgery, which should be done under elective conditions whenever possible. During a short period of time, known as the "risk period" (the time between the hemorrhagic episode and the surgery), propranolol has been used to prevent further bleeding. Surgical treatment is indicated only after the first episode, and never on a prophylactic basis. In 1977, a prospective, randomized trial was begun in order to assess the delayed results of the 3 surgical operations most widely used in this country. The study was interrupted after 94 patients had been operated on due to the high incidence of encephalopathy in the group who underwent classical splenorenal shunt. After a follow-up of at least 60 months and, at most, 130 months, the results showed that classical splenorenal shunt caused encephalopathy in 39.3% of the cases and distal splenorenal shunt in 14.8%. None of those submitted to esophagogastric devascularization with splenectomy developed encephalopathy. The 3 procedures showed similar rates of hemorrhagic recurrence.